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New Trends in organ donation and Transplantation. Juan Carlos Caicedo, MD FACS Di rector, Hispanic Transplant Program Adult transplant Surgeon (NMH) Pediatric Transplant Surgeon (LCH). Overview. Introduction Kidney ( Living / deceased/ combined stem cell) - PowerPoint PPT Presentation
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Northwestern University Feinberg School of Medicine
New Trends in organ donation and
TransplantationJuan Carlos Caicedo, MD FACSDirector, Hispanic Transplant Program
Adult transplant Surgeon (NMH)
Pediatric Transplant Surgeon (LCH)
Overview
Introduction
Kidney ( Living / deceased/ combined stem cell)
Liver: whole, split, reduce size, living donor
2
Who Needs a Transplant?
Transplantation is offered to patients who:
are in end-stage organ failure
have no other surgical or medical option available to them
have a limited life expectancy without a transplant
have undergone a rigorous and thorough assessment process and meet all necessary criteria
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Type of donorsDeceased (dead) donors-Brain dead donors: intact heartbeat & circulation, on ventilator
less than 3% of all deaths
-Donors after cardiac death: occurs in hopeless cases in the hospital where the decision to withdraw life-support is made (decision is independent of the decision to donate). Organ donation occurs immediately once the heart has stopped and the patient is declared dead
Living donor-Patient chooses to donate one or part of an organ to someone on a transplant waiting list
•can only occur with organs when removal will NOT cause grave harm to the donor-
Northwestern University Feinberg School of Medicine
United States Organ Transplantation
OPTN & SRTR Annual Data Report, 2011
Patients on the waiting list on December 31
of the year (active listings only)
Transplants performed during the year (adult & pediatric combined)
First-year all-cause graft survival
Northwestern University Feinberg School of Medicine
Adult Kidney Transplantation
End Stage Renal DiseaseDimension of the problem
>500.000 people in USOptions: Dialysis and kidney transplantationUS kidney waiting list: 105.124 people / 2013
Kidney Failure: Treatment
Kidney Transplantation
“ Best option”- Replace all functions of the kidney- Increase survival and quality of life- Decrease complications- Cost effective
Incident ESRD Rate and Transplant Rate
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USRDS 2010 ADR
Northwestern University Feinberg School of Medicine
2013: 105124 Waiting list2012: 16485 Transplanted 758 ( 4.5%) Pediatric pts
Whites :38%AA: 34%Hispanics: 19%Asian: 8%
Distribution of adult patients waiting for a kidney transplant
Deceased donor kidney donation rates
Cause of death among deceased kidney donors
Organs recovered per donor (ORPD), by SCD, DCD, & ECD status
Delayed graft function among adult kidney transplant recipients
Kidney donations from living donors
Living kidney donation
Laparoscopic vs Open
- Safe
- Less pain
- Fast recovery
- POD 1: Home
- Smaller Incisions
Intended kidney transplant procedure type, & percent of intended laparoscopic procedures converted to open
Number of transplants from living donors, by donor relation
All patients receiving a living donor kidney transplant.
USRDS 2010 ADR
Kidney Transplantation
Kidney Transplantation
Sensitized Patients PRA Levels of Wait-Listed Patients
64%
21%
15%
0-9% 10-79% >80%
Sensitized
Very Highly Sensitized 36% Sensitized
Total = 17,814 pts
2010: 25% Sensitized
Options for Sensitized and ABO incompatible PatientsWait and hope
Desensitization•Live Donor•Deceased Donor
Live Donor Paired Exchange•List Exchange
Wait and hopeDesensitization
Live DonorDeceased Donor
Live Donor Paired ExchangeList Exchange
Paired kidney donations
Basic Kidney Paired Donation (KPD)
Northwestern University Feinberg School of Medicine
Desensitization
30N Engl J Med 365;4 July 28, 2011
Trends in Transplant Medications
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Immunosuppression use in adult kidney transplant recipients
Initial immunosuppression regimen in adult kidney transplant recipients, 2011
Acute rejections within the first year post-transplant
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First-time, kidney-only transplant recipients, age 18 & older, with functioning graft at discharge.
Source: USRDS 2010 ADR
Trends in Transplant Research
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The co-existence of two genetically different components in one organism
Chimerism induces tolerance
Mixed Chimeras
How can we make it safe?
Northwestern Clinical Tolerance ProtocolsSequential kidney/HSC in HLA matched related
Simultaneous kidney/HSC in HLA mismatched
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HLA-Matched Protocol
Current Enrollment – 20/20
First patient enrolled January 2008
HLA identical siblings
Excluded if high risk of recurrent disease in the allograft (role of immunosuppression in preventing disease recurrence)
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PI: Joshua Miller
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HSCT mobilized, collected, processed, & cryopreserved (> 2 wks before Tx)
ConditioningFludarabine, cytoxan, 200 cGy TBI Perform
Transplant
Processed donor leukopheresis product/marrow enriched for
HSC, FC and progenitors (FCRx)
Simultaneous FCRx +Kidney Transplant
d0 d +1
Adult kidney transplants
Outcomes among adult kidney transplant recipients: deceased donor
Outcomes among adult kidney transplant recipients: living donor
Half-lives for adult kidney transplant recipients
Liver Transplantation
Type of donor: Living vs deceased donor
Type of graft: Partial vs whole organ
Whole Organ Orthotopic Liver Transplant
Standard technique. This figure illustrates a completed liver transplant with vascular and biliary anastomoses.
Partial Grafts / Liver transplantation (LTX)
-Reduce Size Ltx-Split LTx-Living Donor Ltx
Partial Liver Transplantation
The split through midplane with right and left lobe graftsReference: Humar A, et al. Amer J Transpl 2001;1:366-72
Schematic drawing of the right lobe after transplantation into the recipient. The major vascular anastomosis and drainage of the bile duct into a Roux loop of bowel is illustrated
Northwestern University Feinberg School of Medicine
Adult Liver Transplantation
48
Distribution of adult patients waiting for a liver transplant
Liver donors who are DCD
Liver transplants from living donors, by donor relation
Living donor liver transplant graft type
Total adult liver transplants
Adult liver transplants
Graft failure among adult liver transplant recipients: deceased donor
Immunosuppression use in adult liver transplant recipients
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ConclusionTransplantation offers a second chance at life to thousands of people. It has been proven over and over again to be very successful. However, transplantation can only occur if someone consents to the ultimate gift – organ and tissue donation.
liver transplant recipient
Kidney donor and recipient
Northwestern University Feinberg School of Medicine
Thank you
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